Maine Patient Safety Academy

New Date Coming Soon | Portland, ME
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Agenda at a Glance

Please note sessions may change.

8:00 am

Registration, Check-in,  and Coffee

Abromson Center Lobby 

9:00 am


Hannaford Hall 

9:15 am

Morning Plenary

Hannaford Hall 

The Medical Errors Leading to Lauren’s Avoidable Death and What I Have Learned to Improve Maternal Safety in Pregnancy

Larry Bloomstein, MD

Orthopedic Surgeon
Red Bank, NJ

10:15 am

Coffee Break, Exhibits & Networking

Abromson Center Lobby


10:30 am

Morning Workshops

Abromson Center 

A Day in the Life: Dementia Simulation

Room 217

Caregivers for persons with dementia, be they medical, professional, family members or friends, are tasked to provide compassionate and empathic responses in the care of their patients or loved ones. Dementia Simulation offers the ability to experience the effects of aging and dementia so that families, friends, and caregivers can gain a broader perspective of what their patients or loved ones may be challenged with on a day-to-day basis. A pre-simulation and post -simulation evaluation is provided.


1.To gain a deeper understanding of the challenges persons with dementia face day-to-day

  1. To experience co-morbidities that older adults with dementia may face, such as neuropathy and vision and hearing impairment.
  2. To learn better communication methods for persons with dementia. 
Holly Bean

University of Southern Maine

Applying the Breaks: Controlled Substance Stewardship

Room 213

This workshop will discuss Penobscot Community Health Care’s Controlled Substance Stewardship program. Participants will be able to identify ways to mitigate opioid prescribing issues while improving patient safety; employ better-informed prescribing/tapering practices; and learn skills for promoting safer, evidence-based treatment of chronic pain.

Noah Nesin, MD
Penobscot Community
Health Care

How ACEs and Social Determinants of Health Compound Chronic Disease Management

Room Number 110

Individuals who have experienced trauma- especially Adverse Childhood Experiences (ACEs), compounded by social determinants of health (SDOH) factors, are at elevated risk for substance use disorders, mental illness, and physical disorders. Learn how Trauma-informed care (TIC), an evidence-based approach that recognizes and responds to the effect trauma has on health, can help you to empower your patients to become a more active participant in their care. In this interactive session, you’ll learn how Healthcentric Advisors is supporting administrators, providers, and staff by providing essential information about adverse childhood experiences, trauma-informed care, and social determinants of health to create a safe environment for their patients to learn how to manage their chronic conditions.


Jennifer McCarthy

HealthCentric Advisors

The Power of Community Paramedicine: Closing a Care Delivery Gap in Rural Maine

Room 214

Through an interactive case study and panel presentation, participants will 1) Understand the role that community paramedicine plays in the healthcare delivery system in Maine; 2) Discuss viewpoints, solutions, and suggestions to the barriers of community Paramedicine;3) Evaluate data provided and make a decision about the need for community Paramedicine.


Dr. Tim Fox


Lindsay Sproul


Rose Merianos


Nicholas Bryant

Central Lincoln County Ambulance Service

Right Care, Right Time, Right Place in Maine

Room 216

The loss of access to healthcare services in Maine communities, such as obstetrics care and emergency medical services, contributes to worsening maldistribution of healthcare capacity, and poses risk to the health and safety of community members. This session invites participants to share their knowledge of factors contributing to demand-capacity mismatches, the effect of demand-capacity mismatches on the timeliness and safety of care, and the strategies being applied to reduce the risk of misadventure in patient care. Information will be shared at the level of themes and conditions, to avoid identification of facilities, providers, and patients.

Jeff Brown

Patient Safety Consultant

Yvonne Jonk

Maine Rural Health Research Center

You Have to Wear Shades: A Bright Future for Maine’s Aging Population

Room 109

This session, designed to be reminiscent of a live podcast will review trends on aging, identify service areas which have harnessed out of the box thinking to drive change, and brainstorm the fundamental needs to encourage patient safety as we head in to the next century of healthcare. Bring your expertise, curiosity and most importantly, voice. This session is meant to help those that lead Maine’s healthcare industry hear from those who care passionately about it.

Danielle Watford

Maine Health Care Association

You Should Not Be “Consenting” Your Patients!

Room 215

This workshop will be led by a multidisciplinary team exploring the following topics:

  • Why informed consent is important
  • What you can bring back to your workplace or academic team

  • Barriers and solutions

Participants will be empowered to advocate for the importance of meaningful informed consent; be able to identify and work around common cognitive, emotional, and situational barriers to meaningful consent; and be able to identify key population groups who are especially vulnerable during the consent process.

Judy Tupper

University of Southern Maine

Carol Nemeroff

University of Southern Maine

Bruce Thompson

University of Southern Maine

Ross Hickey

University of Southern Maine

Sheilan Hamasoor

University of Maine School of Law

11:30 AM


Abromson Center Lobby


12:00 PM

Afternoon Plenary

Hannaford Hall

Heart, Mind, and Grit—Virtuosity is Not an Accident: Speaking up in the 21st Century


Laura Chalmers

Robert Gordon University
Aberdeen, Scotland

12:00 PM

Rising Tide Award Presentation

Hannaford Hall 

1:30 PM

Afternoon Workshops

Abromson Center 

A Day in the Life: Dementia Simulation (Repeat Session)

Room 217

Caregivers for persons with dementia, be they medical, professional, family members or friends, are tasked to provide compassionate and empathic responses in the care of their patients or loved ones. Dementia Simulation offers the ability to experience the effects of aging and dementia so that families, friends, and caregivers can gain a broader perspective of what their patients or loved ones may be challenged with on a day-to-day basis. A pre-simulation and post -simulation evaluation is provided.


1.To gain a deeper understanding of the challenges persons with dementia face day-to-day

  1. To experience co-morbidities that older adults with dementia may face, such as neuropathy and vision and hearing impairment.
  2. To learn better communication methods for persons with dementia. 
Holly Bean

University of Southern Maine

Cultural Humility in Medical Social Work

Room 214

The workshop will address concepts of Cultural Humility and how the social worker in a medical setting can be an agent to ensure a customized plan of care for all patients, specifically advocating for refugees and asylum seekers by being a communication conduit between the patient’s culture and the medical culture.  Participants will understand:

– the difference between cultural awareness and humility

– healthcare as a sub-culture; and

– the role of the medical social worker

Mara Larkin

Maine Medical Center

High Reliability Organizations and the Second Victim

Room 109

High Reliability Organizations (HROs) are those that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures, acknowledge the high-risk nature of their activities, and are determined to achieve consistently safe operations by promoting a safety culture and by going beyond standardization to cultivate resilience by relentless prioritization of safety over other performance measures. Through this workshop, participants will be able to:

1. Define and discuss High Reliability Organizations (HROs) and the impact operating as an HRO can have on patients and employees.

2. Define the term “Second Victim” and understand the recovery trajectory of the second victim, and

3. Appreciate the relationship between second victim, safety culture and high reliability organizations.

Pam Sweeney

VA Maine Healthcare System

Allison Marshall-Spaulding

VA Maine Healthcare System

Leveraging Daily Management System to Strengthen Safety Culture

Room 110

Separate from and in addition to Patient Safety Executive Walk Rounds is the Daily Management System which also engages senior leaders and front line teams to work on local improvements. In keeping with the belief that the ability to raise safety concerns should be real time, we set about leveraging our established Daily Management System at Maine Medical Center (MMC) to strengthen our safety culture at MMC. Following the presentation and discussion of the results at MMC, participants will be able to describe the components of Daily Management Systems; discuss methods to improve culture and transparency; and apply one or two concepts in their work setting.


Erin Graydon-Baker


Suneela Nayak

Maine Medical Center

Looking to the Future: Zero Harm and the Journey Towards High Reliability Healthcare

Room 213

This session is intended to provide a working understanding of the Joint Commission’s High Reliability Model for Healthcare, which includes fourteen areas of performance that are necessary for healthcare organizations to advance toward zero harm.  Participants will also learn about the Oro® 2.0 High Reliability Organizational Assessment, an online tool that is widely available at no cost to Joint Commission-accredited hospitals.  Finally, participants will learn about the key areas where most organizations struggle as well as strategies for improvement, with specific lessons from Critical Access Hospitals. Some of these areas include: physician engagement in quality and safety, quality measurement to promote improvement and transparency, strengthening key safety systems and increasing and sustaining performance improvement capacity.


David Grazman

Center for Transforming Healthcare, Joint Commission

Maine’s CDC Healthcare Epidemiology Program – Your Public Health Partner in Patient Safety
Room 216

Infections, like patients, can move facility to facility, and across state lines. Antibiotic prescribing practices in the ambulatory care settings can impact healthcare associated infection risk in the extended and acute care settings. Emerging threats, such as carbapenemase-producing organisms and Candida auris, present new infection control challenges for healthcare facilities. Public health works to strengthen healthcare facility infection prevention and control and address risk across healthcare facilities and networks. Come and discover what a partnership with public health has to offer. Participate in an exercise to assess your healthcare facility’s readiness to partner with public health to improve patient safety as it relates to healthcare associated infections and antibiotic resistance.

Rita Owsiak

Maine Center for Disease Control

Understanding Trauma Expression in Psychiatric and Substance Using Patients

Room 215

This workshop will provide an overview of how trauma is presented behaviorally in those with psychiatric and substance use disorders and methods of communication to best meet these individuals and nurses’ shared goals to extend an emotionally safe environment. Attendees will also learn brief interpersonal effectiveness and emotional regulation skills from the Dialectical Behavior Therapy model of treatment which can assist in communication during stressful situations to improve patient safety. 

Donna Wampole

University of Southern Maine

2:30 PM

Film Screening: To Err is Human

Hannaford Hall 

Medical mistakes lead to as many as 440,000 preventable deaths every year. To Err Is Human is an in-depth documentary about this silent epidemic and those working quietly behind the scenes to create a new age of patient safety.

Through interviews with leaders in healthcare, footage of real-world efforts leading to safer care, and one family’s compelling journey from victim to empowerment, the film provides a unique look at our healthcare system’s ongoing fight against preventable harm.

Applying the Brakes: Controlled Substance Stewardship

Noah Nesin

In response to the opioid epidemic, Penobscot Community Health Care (PCHC) – a Federally Qualified Health Center based in Bangor, Maine – has partnered with other providers in the region on the development of a Controlled Substances Stewardship (CSS) program that has resulted in a 77% reduction in opioid/benzodiazepine prescribing at PCHC since 2013.
More information about this CSS program will be discussed at Dr. Nesin’s session at 10:30 am.

Creating a Culture of Safety: Exploring Collegiate Coaches’ Attitudes and Perceptions towards Concussion

Dr. Meredith Madden, Dr. Meredith Kneavel, and Dr. William Ernst

The purpose of this study is to understand the beliefs of NCAA Division I, II, & III coaches about their role in concussion management, perspectives about the culture of concussion on their campuses, and their thoughts on concussion safety. As part of a larger survey, qualitative questions included what coaches’ thought their role in concussion management was, what the culture of concussion on campus was, if athletes generally reported, and what their overall thoughts on concussion were. Schools from all three divisions of the NCAA were randomly selected based on the proportions represented (31% DI, 27% DII, 41% DIII). Coach and assistant coach emails from selected colleges of contact/collision or limited contact concussive sports were sent a link to the survey. A phenomenological, inductive approach was used to analyze responses.

Effectiveness of Behavioral Interventions in Improving Hypertension Levels

Kristen Easter, Krisha Shaw, Dr. Kenji Saito, Erin Landry, and Amber Dow

Hypertension is an established risk factor for cardiovascular diseases and is common among obese subjects. High blood pressure (HBP) is a major health problem in the US, affecting more than 50 million people. It is well established that HBP can be lowered pharmacologically in hypertensive individuals; however, anti-hypertensive medications are not effective for everyone, and may be costly and result in adverse effects that impair quality of life and reduce adherence. The main behavioral interventions that are recommended to reduce HBP are the Dietary Approaches to Stop Hypertension (DASH) diet & regular exercise. Weight loss is also recommended for HBP reduction in overweight individuals. This data supports the role of behavioral interventions in the treatment of patients at risk of hypertension.

Epilepsy Monitoring Unit

Lynne Keller

After two incidences on R6 involving patients admitted to the Epilepsy Monitoring Unit, that had high potential to impact patient safety, the R6 Team identified that there was a need for a higher level of staff and companion education around patients admitted with seizures. Both R6 staff and float companions needed to be educated on how to safely care for seizure patients, and how to better recognize and respond to seizures.

The Healthcare Associated Infection (HAI) Surveillance Toolkit for Maine Psychiatric Hospitals: Promoting statewide standardization and sustainability of psychiatric hospital infection surveillance

Hannah Huggins

There are two primary sources used to identify healthcare associated infections (HAIs) in healthcare facilities: McGeer Criteria and the CDC’s National Health and Safety Network (NHSN) definitions. Used independently, both sources fail to address the unique risks associated with psychiatric hospitals (PHs). To combat this problem, the HAI Program of the Maine Center for Disease Control and Prevention (ME CDC) developed the HAI Surveillance Toolkit for Psychiatric Hospitals. The goal of the toolkit is to standardize PH HAI Surveillance statewide. In effect, this will make PH surveillance easier to conduct, and ultimately, improve the quality, efficiency and sustainability of HAI surveillance in PHs. Using discussions among Maine PH IPs, the HAI Program selectively combined existing surveillance criteria to reflect PH-specific infection risks. The program compiled tools and resources, and built worksheets, a data collection and reporting tool, and guiding questions for building a facility-specific surveillance plan. All elements were designed with flexibility in mind, so each facility can easily locate the resources they need to make an individual surveillance plan. The resulting toolkit was shared in virtual and print form with 3 of 4 Maine PH IPs during an in-service meeting. Currently, PH IPs are piloting the toolkit in their respective facilities. It is projected it will improve the quality and sustainability of HAI surveillance statewide. As the first of its kind, the HAI Surveillance Toolkit for Maine PHs brings light to the lack of PH-specific infection prevention resources and increases PH’s potential to conduct accurate HAI surveillance over time.

Incorporating Health Performance Improvement Taxonomy in Occurrence Reporting Platform

Karen Chandler, Lori Key, and Theresa Murray

Utilizing Healthcare Performance Improvement (HPI) taxonomy within an occurrence reporting system to enable a deep dive into each deviation in generally accepted performance standards identified through Root Cause Analysis. This allows for a streamlined common cause analysis process and prioritization of resources within an organization to invest in key process improvements that directly impacts patient outcomes.

Increasing Access to Spiritual Care Services in the Emergency Department: A Patient and Staff Support Model

Rev. Heather Weidemann

Despite extensive evidence that interfaith Spiritual Care reduces emotional distress and improves health outcomes, especially in times of suffering and trauma, appropriate use of Spiritual Care Services is a challenge for busy Emergency Department (ED) staff. At the beginning of this improvement journey, a lack of awareness and collaboration between the Spiritual Care Department and the ED at Maine Medical Center was resulting in numerous missed opportunities to offer needed support. By strategically integrating Spiritual Care and emotional support into the clinical setting, our team increased the percentage of EHR consult orders received by Spiritual Care from ED staff by 10.93 % in 10 months.

Increasing First Case OnTime Starts in an Ambulatory Surgery Center

Diane Fecteau, Shannan Reid, Sydney Green, and Ruth Hanselman

The purpose of this Operational Excellence performance improvement project was to increase the percent of first cases of the day that start on time to 70% or greater in a ten room ambulatory surgery center.” On-time” was defined as starting on or before the scheduled surgery patient in the room time (no “grace period”). Improving on-time first case starts within Maine Medical Center (MMC) Scarborough Surgery Center (SSC) is important as it directly affects the patient experience as well as the respect between members of the operating room team. Patients expect to have a procedure started within a reasonable time after their arrival. When delayed, this causes patient and family anxiety and delays subsequent patients in a cascading impact. Through this initiative, MMC SSC will be positively impacted by improved patient satisfaction, as well as an increase in care team well-being with improved respect, efficiency, and accountability from all team members.
A multidisciplinary First Case On-Time Starts Workgroup was formed and case delay data was collected. A root cause analysis of the causes for late first case starts revealed surgeon late arrival (42%), patient late arrival (16%), and medication issues (8%) accounted for 66% of the late starts. Actions were taken to address these issues, including 1:1 conversations with late surgeons followed by posting names of late surgeons, adjusting patient arrival times for specific patient populations, calling all first case patients the day before to remind of arrival time, and staffing an onsite pharmacist. Outcomes improved and on time first case starts, averaging 50.2% in October 2018, improved to 76% and 69% in May and June, 2019, respectively.

Project RISE: Rapid Induction Starting in the Emergency Department – Streamlining the Patient with OUD Journey in Local Communities in Maine

Kayla Cole

Maine is among the top ten states with the highest rate of substance use disorder/opioid use disorder (SUD/OUD) deaths in the country. In 2017, there were 418 overdose deaths in Maine. This is an increase of more than 150% over the past decade. In response to this public health crisis, Qualidigm established the Caring for ME initiative which focuses on providing education to providers through synchronous and asynchronous methods in order to address the opioid epidemic in Maine. Through education of providers on harm reduction, prevention, and safe prescribing the state of Maine had the largest decrease in opioid prescribing of 25% in just one year.

To highlight these efforts and outcome data, our poster highlights the Rapid Inductions Starting in the ED (RISE) project, an initiative which focuses on the rapid initiation of buprenorphine in the Emergency Department setting for patients with opioid use disorder. This initiative aims to have more EDs in Maine offer induction services to help those seeking treatment for opioid use disorder receive initial medication treatment in the moment with a warm hand off to a community recovery/treatment program. Specifically, our poster explains what the RISE project is, the implementation process including provider education and assistance on best practices using a graphical roadmap approach, qualitative analysis to inform a standardized approach to administering buprenorphine in the ED, conclusions, outcomes and recommendations to encourage effective implementation and to ultimately aid more patients in entering recovery.

Using Shared Decision Making and Team Based Care to Overcome Socioeconomic and Cultural Barriers to Colorectal Cancer Screenings

Dr. Amanda Powell and Kristin Rowse

Colorectal cancer disproportionally affects minorities and those in lower socioeconomic groups. As one of the oldest and most rural states in the nation, Maine has needed to be innovative in its efforts to screen the growing population of eligible patients. Additionally, our particular patient population is comprised of many newly arrived immigrants to the US, which presents additional challenges for cancer screening. Annual use of fecal immunochemical testing (FIT) represents a low barrier, low cost and low risk screening tool with the potential to reach patients that might otherwise never be screened for colorectal cancer. In appropriate patients, FIT use offers the opportunity to overcome social determinants of health, such as low health literacy, lack of access to care in rural communities and other socioeconomic barriers. We utilized FIT testing in appropriate patients and then leveraged the personal relationships of our front office staff with our patients to increase the return rates of those FIT kits.